- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.08 / $1,635.08 / $1,635.08
| Professional | | $1,635.08 | $1,635.08 | $1,635.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,736.00 / $4,213.00 / $5,056.00
| Professional | | $3,736.00 | $4,213.00 | $5,056.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,478.39 / $2,481.48 / $4,143.14
| Professional | | $2,478.39 | $2,481.48 | $4,143.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,088.06 / $5,394.74 / $7,110.86
| Professional | | $2,088.06 | $5,394.74 | $7,110.86 |